Factors Facilitating and Challenges Facing Community-based Interventions in Improving Antenatal Care in Rural Tanzania
Corresponding Author(s) : Stephen Maluka
Journal of Humanities & Social Science (JHSS),
##issue.vol## 10 ##issue.no## 4 (2021)
##article.abstract##
The improvement of antenatal care has remained a topical global concern as signalled by maternal deaths, which have remained unacceptably high, especially in low- and middleincome countries. In response to this concern, community-based interventions through women’s groups have been implemented to improve antenatal care; and have shown promising results in rural settings. However, factors contributing to the success or failure of these interventions vary across geographical settings, thereby necessitating areaspecific considerations. This paper sets out to unveil significant facilitators and barriers to the implementation of women’s group interventions in Tanzania. A qualitative case study design was employed involving interviews, focus group discussions, and documentary review in Kilolo and Mufindi districts. Eighty-six participants were interviewed and six small focus group discussions were conducted. Findings show that several factors facilitated the implementation of community-based interventions. These included recruitment and selection of the women’s groups, readiness among the women’s groups, support of the local administrative systems, and inclusive monitoring and evaluation process. On the other hand, the implementation process was constrained by insufficient logistical supplies, multiple workloads, and the desire for allowances. It is concluded that increased uptake and sustainability of antenatal care can potentially be attained through an understanding of both facilitators and barriers during the planning, development and implementation of the interventions of women’s groups.
##submission.howToCite.downloadCitation##
##plugins.generic.citationStyleLanguage.download.ris####plugins.generic.citationStyleLanguage.download.bibtex##
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Advancing the Application of Systems Thinking in Health: Analysing the Contextual and Social Network Factors Influencing the Use of Sustainability Indicators in a Health System--A Comparative Study in Nepal and Somaliland. Health Research Policy and Systems, 26(12): 46. Boakye, M.D.S., C.J. Owek, E. Oluoch, J. Wachira & Y.A. Afrane. 2018. Challenges of Achieving Sustainable Community Health Services for Community Case Management of Malaria. BMC Public Health,18: 1150. Braun, V. & Clarke, V. 2006. Using Thematic Analysis in Psychology. Qualitative Research Psychology: 3(2): 77–101. Chatio, S., P. Welaga, P.T.N. Tabong, & P. Akweongo. 2019. Factors Influencing Performance of Community-Based Health Volunteers’ Activities in the Kassena-Nankana Districts of Northern Ghana. Plos ONE.14(2): 14(2). Colbourn, T., B. Nambiar, A. Bondo, C. Makwenda & E. Tsetekani. 2013. Effects of Quality Improvement in Health Facilities and Community Mobilisation Through Women's Groups on Maternal, Neonatal and Perinatal Mortality in Three Districts of Malawi: Maikhanda, a Cluster Randomised Controlled Effectiveness Trial. International Health, 5(3): 180–95. Cole, E., M. Wells, M. Maxwell, M.F. Harris, J. Anderson, M.N. Gray & G. Milner. 2017. The Influence of Contextual Factors on Healthcare Quality Improvement Initiatives: What Works, for Whom and in What Setting? Protocol for a Realist Review. Systematic Reviews, 6: 168. Dopson. S. & L.A. Fitzgerald. 2005. The Active Role of Context. In: Dopson S, Fitzgerald LA, Editors. Knowledge to Action? Evidence-Based Health Care in Context. Oxford: Oxford University Press. pp. 79–102. Earsido, A., A. Gebeyehu, & T. Kisi. 2015. Determinants of Longa Acting and Permanent Contraceptives Methods Utilisation Among Married Women in Hossana Town. Southern Ethiopia: A Case-Control Study. 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Johnson. 2015.The Oxford Handbook of Multi-Method and Mixed Methods Research Inquiry. Oxford. Oxford University Press. Howard-Grabmanl, L., A.S., Miltenburg, Marston & C.A. Portela. 2017. Factors Affecting Effective Community Participation in Maternal and Newborn Health Programme Planning, Implementation and Quality of Care Interventions. BMC Pregnancy and Childbirth, 17: 268. . Indriani, D. 2012. Community Participation as a Strategy in Reducing Maternal and Child Mortality in Rural Areas: A Literature Review. MSc International Health. Centre for International Health, University of Bergen, Norway. Iwelunmor, J., S. Blackstone, D. Veira, U. Nwaozuru, & C. Airhihenbuwa. 2016. Toward the Sustainability of Health Interventions Implemented in Sub-Saharan Africa: A Systematic Review and Conceptual Framework. Implementation Science, 11: 45. Jacobs, C., C. Michelo & M. Moshabela. 2018. Implementation of Community-Based Interventions in the Most Rural and Remote Districts of Zambia: A Process Evaluation of Safe Motherhood Action Groups. Implementation Science, 13: 74. Jaribu, J., S. Penfold, C. Green, F. Manzi & J. Schellenberg. 2018. Improving Tanzanian Childbirth Service Quality. International Journal of Health Care Quality Assurance, 31(3): 190–202. Jaskiewicz, W. & K. Tulenko. 2012. Increasing Community Health Worker Productivity and Effectiveness: A Review of the Influence of the Work Environment. Hum Resource Health, 10(1): 38. Kalipeni, E., J. Iwelunmor & D.G. Toussaint. 2017. Maternal and Child Health in Africa for Sustainable Development Goals Beyond 2015.Global Public Health,12: 6, 643–647. Kante, A.M., A. Exavery, E.F. Jackson, T. Kassimu, D.C. Baynes, A. Hingora, & J. Phillips. 2019. The Impact of Paid Community Health Worker Deployment on Child Survival: The Connect Randomized Cluster Trial in Rural Tanzania. BMC Health Services Research. 19: 492. 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Leaving No One Behind: Using Action Research to Promote Male Involvement in Maternal and Child Health in Iringa Region, Tanzania. BMJ Open, 10: E038823. Macphail, C. 2006. Youth-Driven HIV Prevention Programmes in South Africa: Social Capital, Empowerment and Conscientisation. Social Dynamics. 32(2): 170–196. Mannah, M.T., C. Warren, S. Kuria & A. Adegoke. 2014. Opportunities and Challenges in Implementing Community-Based Skilled Birth Attendance Strategy in Kenya. BMC Pregnancy and Childbirth, 14: 279. Miltenburg, A.S., S. Van Pelt, W. De Bruin & L. Shields-Zeeman. 2019. Mobilizing Community Action to Improve Maternal Health in a Rural District in Tanzania: Lessons Learned from Two Years of Community Group Activities. Global Health Action, 12: 1621590. Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) & ICF. 2016. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015–16. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: Mohcdgec, MoH, NBS, OCGS, and ICF. Ministry of Health and Social Welfare (MHSW). 2015. Tanzania Health Sector Strategic Plan 2015– 2020(HSSP IV). Reaching All Households With Quality Health Care. Dar es Salaam: MHSW. Moller, A.B., J.H. Patten, C. Hanson, A. Morgan, L. Say, T. Diaz & A. Moran. 2019. Monitoring Maternal and Newborn Health Outcomes Globally: A Brief History of Key Events and Initiatives. Tropical Medicine and International Health, 24(2): 1342–1368. Mpembeni, R.N.M., A. Bhatnagar, A. Lefevre, D. Chitama, D. Urassa, C. Kilewo, R.M. Mdee, H. Semu & P.J. Winch. 2015. Motivation and Satisfaction Among Community Health Workers in Morogoro Region, Tanzania: Nuanced Needs and Varied Ambitions. Human Resources for Health, 13: 44. Mufindi District Council (MDC). 2018. Comprehensive Council Health Management Plan for the Year 2017/2018. Mushi, D., R. Mpembeni & A. Jahn. 2010. Effectiveness of Community-Based Safe Motherhood Promoters in Improving the Utilization of Obstetric Care: The Case of Mtwara Rural District in Tanzania. BMC Pregnancy and Childbirth, (10)14. Ngilangwa, D.P. & G.S. Mgomella. 2018. Factors Associated With Retention of Community Health Workers in Maternal, Newborn and Child Health Programme in Simiyu Region, Tanzania. Africa Journal of Primary Health Care Family Medicine, 10(1): A1506. doi: https: //doi.org/10.4102/ phcfm.v10i1.1506. Osawa, E., T. Kodama & E. Kundishora. 2010. Motivation and Sustainability of Care Facilitators Engaged in a Community Home-Based HIV/AIDS Program in Masvingo Province, Zimbabwe. AIDS Care, 22: 895–902. Panday, S., P. Bissell, E. Teijlingen Van & P. Simkhada. 2017. The Contribution of Female Community Health Volunteers (Fchvs) to Maternity Care in Nepal: A Qualitative Study. BMC Health Services Research, 17: 623. Paxman, J. M., A. Sayeed, A. Buxbaum,. S.C. Huber & C. Stover. 2005. The India Local Initiatives Program: A Model for Expanding Reproductive and Child Health Services. Studies in Family Planning, 36(3): 203–20. Prost, A., T. Colbourn, N. Seward, Azad, K. Coomarasamy, A. Copas & A. Costelo. 2013. Women’s Groups Practising Participatory Learning and Action to Improve Maternal and Newborn Health in Low-Resource Settings: A Systematic Review and Meta-Analysis. Lancet, 381: 1736–46. Scott, S. L. Kendall, P. Gomez, P. Howie & S.Z. Syed. 2017. Effects of Maternal Death on Child Survival in Rural West Africa: 25 Years of Prospective Surveillance Data in the Gambia. Plos ONE, 12(2): E0172286. Sinha, D. 2008. Empowering Communities to Make Pregnancy Safer: An Intervention in Rural Andhra Pradesh. Population Council: New Delhi. Sondaal, A., K.M. Tumbahangphe, R. Neupane, D.S. Manandhar, A. Costello & A.C. Morrison, 2018. Sustainability of Community-Based Women's Groups: Reflections from a Participatory Intervention for Newborn and Maternal Health in Nepal. Community Development Journal, 54(4): 731–749. Tuncalp. ?., J.P. Pena-Rosas, T. Lawrie, M. Bucagu, O.T. Oladapo, A. Portela & A.M. Gulmezoglu. 2017. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience Going Beyond Survival. BJOG; 124: 860–862. Wells, M., B. Williams, S. Treweek, J. Coyle, & J. Taylor, 2012. Intervention Description is Not Enough: Evidence from an In-Depth Multiple Case Study on the Untold Role and Impact of Context in Randomised Controlled Trials of Seven Complex Interventions. Trials, 13(95). Woldie, H.F., A.T. Tsegaye & M.M. Sisay, 2019. Late Initiation of Antenatal Care and Associated Factors Among Pregnant Women in Addis Zemen Primary Hospital, South Gondar, Ethiopia. BMC Reproductive Health, 16(73). doi: 10.1186/s12978–019–0745–2. World Health Organization (WHO). 2016. WHO Recommendation on Antenatal Care for Positive Pregnancy Experience. (WHO). http: //www. who.int/reproductivehealth/ publications/ maternal_ perinatal_ health/anc-positive-pregnancy-experience/en/ accessed on 3rd april, 2020. Yin, R.K. 2009. Case Study Research: Design and Methods (4 Ed.). Los Angeles, CA: Sage.
##journal.references##
Ahluwalia, I.B., D. Robinson, L. Vallely, K.E. Gieseker & A. Kabakama. 2010. Sustainability of Community-Capacity to Promote Safer Motherhood in Northwestern Tanzania: What Remains? Global Health Promotion,17(1): 39–49. Azad, K., S. Barnett, B. Banerjee, S. Shaha, A.R. Rego & A. Costello, 2010. Effect of Scaling Up Women’s Groups on Birth Outcomes in Three Rural Districts in Bangladesh: A ClusterRandomised Controlled Trial. Lancet, 375: 1193–202. Bintabara, D., K. Nakamura, J. Ntwenya, K. Seino & B.C.T. Mpondo, 2019. Adherence to Standards of First-Visit Antenatal Care Among Providers: A Stratified Analysis of Tanzanian Facility-Based Survey for Improving the Quality of Antenatal Care. Plos ONE. 14(5): E0216520. Blanchet, K., Palme, J., R. Palanchowke, D. Boggs, A. Jama & Girois, A. 2014. Advancing the Application of Systems Thinking in Health: Analysing the Contextual and Social Network Factors Influencing the Use of Sustainability Indicators in a Health System--A Comparative Study in Nepal and Somaliland. Health Research Policy and Systems, 26(12): 46. Boakye, M.D.S., C.J. Owek, E. Oluoch, J. Wachira & Y.A. Afrane. 2018. Challenges of Achieving Sustainable Community Health Services for Community Case Management of Malaria. BMC Public Health,18: 1150. Braun, V. & Clarke, V. 2006. Using Thematic Analysis in Psychology. Qualitative Research Psychology: 3(2): 77–101. Chatio, S., P. Welaga, P.T.N. Tabong, & P. Akweongo. 2019. Factors Influencing Performance of Community-Based Health Volunteers’ Activities in the Kassena-Nankana Districts of Northern Ghana. Plos ONE.14(2): 14(2). Colbourn, T., B. Nambiar, A. Bondo, C. Makwenda & E. Tsetekani. 2013. Effects of Quality Improvement in Health Facilities and Community Mobilisation Through Women's Groups on Maternal, Neonatal and Perinatal Mortality in Three Districts of Malawi: Maikhanda, a Cluster Randomised Controlled Effectiveness Trial. International Health, 5(3): 180–95. Cole, E., M. Wells, M. Maxwell, M.F. Harris, J. Anderson, M.N. Gray & G. Milner. 2017. The Influence of Contextual Factors on Healthcare Quality Improvement Initiatives: What Works, for Whom and in What Setting? Protocol for a Realist Review. Systematic Reviews, 6: 168. Dopson. S. & L.A. Fitzgerald. 2005. The Active Role of Context. In: Dopson S, Fitzgerald LA, Editors. Knowledge to Action? Evidence-Based Health Care in Context. Oxford: Oxford University Press. pp. 79–102. Earsido, A., A. Gebeyehu, & T. Kisi. 2015. Determinants of Longa Acting and Permanent Contraceptives Methods Utilisation Among Married Women in Hossana Town. Southern Ethiopia: A Case-Control Study. Journal of Pregnancy and Child Health, 2: 165. Gall, M.D., J.P. Gall & Borg, W.R. 2007. Educational Research: An Introduction (8th Ed.). New York. Geldsetzer, P., E. Mboggo, E. Larson, I.A. Lema, L. Magesa & L. Machumi. 2019. Community Health Workers to Improve Uptake of Maternal Healthcare Services: A Cluster-Randomized Pragmatic Trial in Dar es Salaam, Tanzania. Plos Medicine, 16(3): E1002768. George, A.S., K. Scott, V. Mehra & V. Sriram. 2016. Synergies, Strengths and Challenges: Findings on Community Capability from a Systematic Health Systems Research Literature Review. BMC Health Services Research,16(Suppl7): 623. Glasgow, R.E. 2008. What Types of Evidence Are Most Needed to Advance Behavioural Medicine? Annals of Behavioural Medicine. 35(1): 19–25. doi.org/10.1007/s12160–007–9008–5. Glenton, C., C.J. Colvin, B. Swartz Carlsen, S. A. Lewin & J. Noyes. 2013. Barriers and Facilitators to the Implementation of Lay Health Worker Programmes to Improve Access to Maternal and Child Health: Qualitative Evidence Synthesis (Review). Cochrane Database of Systematic Reviews, Issue 10. Art. No. Gong, E., J. Dula, C. Alberto, A. Albuquerque, M. Steenland, Q. Fernades, & R.M. Cuco. 2019. Client Experiences With Antenatal Care Waiting Times in Southern Mozambique. BMC Health Services Research. 19: 538. Gram, L., J. Morrison, N. Saville, B. Shrestha, A. Costello & J. Worrall. 2018. Do Participatory Learning and Action Women’s Groups Alone or Combined With Cash or Food Transfers Expand Women’s Agency in Rural Nepal. Journal of Development Studies, 55(8): 1670–1686, doi: 10.1080/00220388.2018.1448069. Haruna, U., G. Dandeebo & S.Z. Gala. 2019. Improving Access and Utilization of Maternal Healthcare Services Through Focused Antenatal Care in Rural Ghana: A Qualitative Study. Advances in Public Health: Article ID 9181758,11. Hesse-Biber, S. & B. Johnson. 2015.The Oxford Handbook of Multi-Method and Mixed Methods Research Inquiry. Oxford. Oxford University Press. Howard-Grabmanl, L., A.S., Miltenburg, Marston & C.A. Portela. 2017. Factors Affecting Effective Community Participation in Maternal and Newborn Health Programme Planning, Implementation and Quality of Care Interventions. BMC Pregnancy and Childbirth, 17: 268. . Indriani, D. 2012. Community Participation as a Strategy in Reducing Maternal and Child Mortality in Rural Areas: A Literature Review. MSc International Health. Centre for International Health, University of Bergen, Norway. Iwelunmor, J., S. Blackstone, D. Veira, U. Nwaozuru, & C. Airhihenbuwa. 2016. Toward the Sustainability of Health Interventions Implemented in Sub-Saharan Africa: A Systematic Review and Conceptual Framework. Implementation Science, 11: 45. Jacobs, C., C. Michelo & M. Moshabela. 2018. Implementation of Community-Based Interventions in the Most Rural and Remote Districts of Zambia: A Process Evaluation of Safe Motherhood Action Groups. Implementation Science, 13: 74. Jaribu, J., S. Penfold, C. Green, F. Manzi & J. Schellenberg. 2018. Improving Tanzanian Childbirth Service Quality. International Journal of Health Care Quality Assurance, 31(3): 190–202. Jaskiewicz, W. & K. Tulenko. 2012. Increasing Community Health Worker Productivity and Effectiveness: A Review of the Influence of the Work Environment. Hum Resource Health, 10(1): 38. Kalipeni, E., J. Iwelunmor & D.G. Toussaint. 2017. Maternal and Child Health in Africa for Sustainable Development Goals Beyond 2015.Global Public Health,12: 6, 643–647. Kante, A.M., A. Exavery, E.F. Jackson, T. Kassimu, D.C. Baynes, A. Hingora, & J. Phillips. 2019. The Impact of Paid Community Health Worker Deployment on Child Survival: The Connect Randomized Cluster Trial in Rural Tanzania. BMC Health Services Research. 19: 492. Kilolo District Council (KDC). 2018. Comprehensive Council Health Management Plan for the Year 2016/2017. Kok, M.C., M. Dieleman, M. Taegtmeyer, J.E.W. Broerse, S.S. Kane & H. Ormel. 2015. Which Intervention Design Factors Influence Performance of Community Health Workers in Low- and Middle-Income Countries? a Systematic Review. Health Policy and Planning, 30: 1207–1227. Lassi, S.Z. & Z.A. Bhutta. 2013. Risk Factors and Interventions Related to Maternal and PrePregnancy Obesity, Pre-Diabetes and Diabetes for Maternal, Fetal and Neonatal Outcomes: A Systematic Review. Expert Review of Obstetrics and Gynecology, 8(6). Lassi, Z.S. & Z.A. Bhutta. 2015. Community-Based Intervention Packages for Reducing Maternal and Neonatal Morbidity and Mortality and Improving Neonatal Outcomes. Cochrane Database of Systematic Reviews, Issue 3. Art. No. CD007754. Maluka, S., P. Japhet, S. Fitzgerald, A. May & P. Kamuzora. 2020. Leaving No One Behind: Using Action Research to Promote Male Involvement in Maternal and Child Health in Iringa Region, Tanzania. BMJ Open, 10: E038823. Macphail, C. 2006. Youth-Driven HIV Prevention Programmes in South Africa: Social Capital, Empowerment and Conscientisation. Social Dynamics. 32(2): 170–196. Mannah, M.T., C. Warren, S. Kuria & A. Adegoke. 2014. Opportunities and Challenges in Implementing Community-Based Skilled Birth Attendance Strategy in Kenya. BMC Pregnancy and Childbirth, 14: 279. Miltenburg, A.S., S. Van Pelt, W. De Bruin & L. Shields-Zeeman. 2019. Mobilizing Community Action to Improve Maternal Health in a Rural District in Tanzania: Lessons Learned from Two Years of Community Group Activities. Global Health Action, 12: 1621590. Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) & ICF. 2016. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015–16. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: Mohcdgec, MoH, NBS, OCGS, and ICF. Ministry of Health and Social Welfare (MHSW). 2015. Tanzania Health Sector Strategic Plan 2015– 2020(HSSP IV). Reaching All Households With Quality Health Care. Dar es Salaam: MHSW. Moller, A.B., J.H. Patten, C. Hanson, A. Morgan, L. Say, T. Diaz & A. Moran. 2019. Monitoring Maternal and Newborn Health Outcomes Globally: A Brief History of Key Events and Initiatives. Tropical Medicine and International Health, 24(2): 1342–1368. Mpembeni, R.N.M., A. Bhatnagar, A. Lefevre, D. Chitama, D. Urassa, C. Kilewo, R.M. Mdee, H. Semu & P.J. Winch. 2015. Motivation and Satisfaction Among Community Health Workers in Morogoro Region, Tanzania: Nuanced Needs and Varied Ambitions. Human Resources for Health, 13: 44. Mufindi District Council (MDC). 2018. Comprehensive Council Health Management Plan for the Year 2017/2018. Mushi, D., R. Mpembeni & A. Jahn. 2010. Effectiveness of Community-Based Safe Motherhood Promoters in Improving the Utilization of Obstetric Care: The Case of Mtwara Rural District in Tanzania. BMC Pregnancy and Childbirth, (10)14. Ngilangwa, D.P. & G.S. Mgomella. 2018. Factors Associated With Retention of Community Health Workers in Maternal, Newborn and Child Health Programme in Simiyu Region, Tanzania. Africa Journal of Primary Health Care Family Medicine, 10(1): A1506. doi: https: //doi.org/10.4102/ phcfm.v10i1.1506. Osawa, E., T. Kodama & E. Kundishora. 2010. Motivation and Sustainability of Care Facilitators Engaged in a Community Home-Based HIV/AIDS Program in Masvingo Province, Zimbabwe. AIDS Care, 22: 895–902. Panday, S., P. Bissell, E. Teijlingen Van & P. Simkhada. 2017. The Contribution of Female Community Health Volunteers (Fchvs) to Maternity Care in Nepal: A Qualitative Study. BMC Health Services Research, 17: 623. Paxman, J. M., A. Sayeed, A. Buxbaum,. S.C. Huber & C. Stover. 2005. The India Local Initiatives Program: A Model for Expanding Reproductive and Child Health Services. Studies in Family Planning, 36(3): 203–20. Prost, A., T. Colbourn, N. Seward, Azad, K. Coomarasamy, A. Copas & A. Costelo. 2013. Women’s Groups Practising Participatory Learning and Action to Improve Maternal and Newborn Health in Low-Resource Settings: A Systematic Review and Meta-Analysis. Lancet, 381: 1736–46. Scott, S. L. Kendall, P. Gomez, P. Howie & S.Z. Syed. 2017. Effects of Maternal Death on Child Survival in Rural West Africa: 25 Years of Prospective Surveillance Data in the Gambia. Plos ONE, 12(2): E0172286. Sinha, D. 2008. Empowering Communities to Make Pregnancy Safer: An Intervention in Rural Andhra Pradesh. Population Council: New Delhi. Sondaal, A., K.M. Tumbahangphe, R. Neupane, D.S. Manandhar, A. Costello & A.C. Morrison, 2018. Sustainability of Community-Based Women's Groups: Reflections from a Participatory Intervention for Newborn and Maternal Health in Nepal. Community Development Journal, 54(4): 731–749. Tuncalp. ?., J.P. Pena-Rosas, T. Lawrie, M. Bucagu, O.T. Oladapo, A. Portela & A.M. Gulmezoglu. 2017. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience Going Beyond Survival. BJOG; 124: 860–862. Wells, M., B. Williams, S. Treweek, J. Coyle, & J. Taylor, 2012. Intervention Description is Not Enough: Evidence from an In-Depth Multiple Case Study on the Untold Role and Impact of Context in Randomised Controlled Trials of Seven Complex Interventions. Trials, 13(95). Woldie, H.F., A.T. Tsegaye & M.M. Sisay, 2019. Late Initiation of Antenatal Care and Associated Factors Among Pregnant Women in Addis Zemen Primary Hospital, South Gondar, Ethiopia. BMC Reproductive Health, 16(73). doi: 10.1186/s12978–019–0745–2. World Health Organization (WHO). 2016. WHO Recommendation on Antenatal Care for Positive Pregnancy Experience. (WHO). http: //www. who.int/reproductivehealth/ publications/ maternal_ perinatal_ health/anc-positive-pregnancy-experience/en/ accessed on 3rd april, 2020. Yin, R.K. 2009. Case Study Research: Design and Methods (4 Ed.). Los Angeles, CA: Sage.